A nurse is providing teaching to an assistive personnel (AP) about the application of wrist restraints to a client. Which of the following instructions should the nurse include in the teaching?
Secure the client's restraints with a square knot
Attach the restraints to the fixed portion of the frame of the client's bed
Remove the client's restraints every 2 hours
Allow 1 fingerbreadth between the restraint and the client's wrists
The Correct Answer is B
A. Secure the client's restraints with a square knot
This is incorrect because square knots are difficult to release in an emergency. Quick-release knots are recommended for safety.
B. Attach the restraints to the fixed portion of the frame of the client's bed
This is correct because attaching restraints to the bed frame ensures they remain stable and do not pose a risk if the bed position changes. Restraints should never be attached to movable parts like side rails, as this can lead to injury.
C. Remove the client's restraints every 2 hours
This is a common practice, but not specific enough for the primary focus of the question. While restraints should be removed periodically to check for circulation, skin integrity, and range of motion, the interval might vary based on institutional policy and patient needs.
D. Allow 1 fingerbreadth between the restraint and the client's wrists
This is incorrect because the proper fit is typically 2 fingers to ensure the restraint is snug but not too tight, preventing circulation issues or injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Returning unused supplies from the bedside to the unit's supply stock is an appropriate action to include in the cost-containment plan. This action prevents waste and saves money by reusing the supplies that are not contaminated or expired.
Choice B reason: Using clean gloves rather than sterile gloves for colostomy care is not an appropriate action to include in the cost-containment plan. This action compromises the quality and safety of care by increasing the risk of infection and cross-contamination. Sterile gloves are required for colostomy care to prevent introducing microorganisms into the stoma or the pouch.
Choice C reason: Storing opened bottles of normal saline in a refrigerator for up to 48 hours is not an appropriate action to include in the cost-containment plan. This action violates the infection control and medication administration policies. Opened bottles of normal saline should be discarded after 24 hours or after a single use, depending on the facility's protocol. Refrigerating the bottles does not extend their shelf life or sterility.
Choice D reason: Waiting to dispose of sharps containers until they are completely full is not an appropriate action to include in the cost-containment plan. This action poses a hazard and a liability for the staff and the clients. Sharps containers should be disposed of when they are three-quarters full or according to the manufacturer's instructions. Overfilling the containers can cause needlestick injuries or spillage of contaminated materials.
Correct Answer is D
Explanation
Choice A reason: A middle adult client who leaves the facility against medical advice does not require the involvement of the ethics committee. The nurse should document the client's decision, inform the provider, and provide discharge instructions.
Choice B reason: A young adult client who is participating in a medical research study does not require the involvement of the ethics committee. The nurse should ensure that the client has given informed consent and is aware of the potential risks and benefits of the study.
Choice C reason: An older adult client who has advance directives on file does not require the involvement of the ethics committee. The nurse should respect the client's wishes and follow the directives in case of a life-threatening situation.
Choice D reason: An adolescent client whose parents refuse a blood transfusion for religious reasons requires the involvement of the ethics committee. The nurse should consult the ethics committee to help resolve the conflict between the parents' beliefs and the client's best interests. The ethics committee can also provide guidance on the legal and ethical implications of the situation.
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